Smith 
The  Nutrition  Class 


THE  LIBRARY 


OF 


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OF 


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NUTRITION 
CLASS 


THE 
NUTRITION  CLASS 

By  Charles  Hendee  Smith,   M.D. 


NUTRITION   CLASSES  ARE   REALLY 
HEALTH   GLASSES" 


/ 

Health  in  Education 


"No  matter  where  the  class 
is  conducted,   success  or 
failure  will  depend  upon 
the     personality     and 
insight  of   the  class 
leader  rather  than 
upon  the  situation 
or   equipment" 


CHILD   HEALTH   ORGANIZATION 

OF    AMERICA 

Perm  Terminal  Building,  370  Seventh  Avenue 
New    York    City 

SOUTHERN  BRANCH, 

UNIVERSITY  Of  CALIFORNIA 

LIBRARY, 

COSANnFL-'c    CALIF. 

78349 


PRESS  OF 
CLARENCES.  NATHAN,  INC.,  REVISED   EDITION  OF 

How  TO  CONDUCT  A  NUTRITION  CLASS 
DECEMBER  1921. — 10,000 


"2. 


! 


1 

v 


THE  NUTRITION 
CLASS 

HE  study  of  large  numbers  of  undernourished 
children  during  the  past  few  years  has  made 
it  plain  that  malnutrition  is  not  a  disease  but 
merely  a  symptom,  which  may  result  from 
many  different  causes.  Furthermore,  the 
individual  child  is  rarely  underweight  from  a  single  cause, 
but  there  are  many  and  complex  factors  in  almost  every 
case.  These  facts  must  be  constantly  remembered  in 
considering  methods  of  treatment.  No  single  plan  will 
reach  all  of  these  children. 

In  organizing  a  Nutrition  Class  it  is  not  sufficient  to 
select  a  group  of  children  who  "look  thin"  and  to  lecture 
them  on  their  diet  and  habits  of  life.  In  order  to  avoid 
serious  errors  it  is  necessary  to  understand  something  of 
the  nature  and  causes  of  malnutrition. 

The  state  of  a  child's  nutrition  is,  in  general,  a  very 
good  index  of  his  health.  A  thin  child  is  seldom  a  well 
child.  A  plump  and  rosy  one  is  usually  healthy.  If  a 
child  has  not  grown  normally  and  has  not  been  able  to 
store  up  fat  and  develop  good  muscles,  it  is  safe  to  infer 
that  he  has  not  had  uniformly  good  health.  The  solution 
of  the  malnutrition  problem  in  the  individual  child  must 
consist  in  seeking  out  the  causes  of  ill  health  and  in  so 
far  as  possible  in  removing  them  or  in  counteracting  them 
when  they  cannot  be  removed.  In  other  words,  a  careful 


The  Nutrition  Class 


diagnosis  must  be  made  on  every  child  who  shows  the  effect 
of  ill  health  in  his  defective  nutrition,  before  any  plan  of 
treatment  can  be  considered. 

A  Nutrition  Class  is  an  Attractive  School 


Ethical  Culture  School  Children 
Supervised  by  Federation  of  Child  Study 

DIAGNOSIS 

THE  complete  diagnosis  must  always  remain  a  medical 
matter,  for  only  a  trained  physician  can  discern  the 
more  obscure  causes,  some  of  which  are  very  common. 
Teachers,  social  workers  and  dietitians  can  do  the  routine 
work  of  conducting  a  nutrition  class,  but  unless  they  have 
some  medical  help,  grave  errors  may  easily  be  made.     It  is 
quite  true  that  the  medical  profession  is  only  just  begin- 
ning  to  be   aware   of    the    importance    of    nutrition  as  a 
measure  of  health  and  that  the  physician,  too,  needs  edu- 
cation in  this  whole  matter. 


The  Nutrition  Class 


The  diagnosis  of  malnutrition  must  consider  two  ques- 
tions : 

FIRST,  Is  the  child  undernourished? 

SECOND,  What  is  the  cause  of  the  undernutrition? 

In  order  to  answer  the  first  question,  the  weight,  height 
and  age  should  be  taken.  The  child  should  be  measured 
without  shoes,  and  weighed  in  his  indoor  clothes,  without 
shoes  or  coat.  The  age  in  years  and  months  (and  the  date 
of  birth)  should  be  noted.  A  table  of  standards  should  be 
at  hand  from  which  the  average  weight  for  height  and  age 
may  be  found.  The  amount  and  percentage  of  the  child's 
underweight  are  then  easily  determined.  The  necessary 
equipment  is  simple — good  scales,  a  measuring  rod  and  a 
table  of  standards.  Any  child  10%  or  more  under  the 
standard  for  height  and  age  may  be  considered  as  definitely 
undernourished . 

It  is  not  sufficient  to  determine  the  weight  deficit  alone. 
One  must  consider  the  elements  which,  from  the  point  of 
nutrition,  make  up  the  child's  weight.  These  are  chiefly  fat 

and    muscle,    and  either 
Mother    and   Johnny   Anxiously 
Watching  the  Verdict 


of  the  Scales 


may  be  deficient.  The 
weight  of  the  bones  differs 
somewhat  in  children  of 
the  same  height  but  it  is 
only  occasionally  a  large 
factor  in  the  weight  vari- 
ation. 

Some  children  show 
a  weight  deficit  due '  to 
poor  muscles,  but  have 
an  amount  of  fat  which 
makes  them  look  fairly 
nourished.  Other  child- 
ren are  very  muscular 


The  Nutrition  Class 


but  have  almost  no  fat.  These  are  really  less  well  nourished 
than  is  indicated  by  the  height  and  weight  ratio. 

There  are  two  general  types  of  undernourished  children. 
The  first  is  apathetic,  listless  and  pale,  with  poor  muscles 
and  fat,  round  shoulders,  bad  posture  and,  usually,  other 
defects.  The  second  is  the  overactive  child  who  is  ner- 
vous, restless  and  never  still.  He  generally  has  good 
muscular  development  but  very  little  fat. 

The  second  step  is  to  determine  the  causes  of  malnutri- 
tion. It  is  necessary  to  make  a  careful  study  of  the  entire 
history  of  the  child's  life,  as  well  as  of  his  present  condition 
and  daily  routine. 

THE  CAUSES    MAT    BE  DIVIDED    INTO 
FIFE  MAIN  GROUPS: 

I. — Inheritance. 

II. — Past  Illness. 
III. — Present  Defects  or  Disease. 
IV. — Bad  Hygiene  and  Improper  Diet. 

V. — Social  Factors  and  Environment. 

I.— INHERITANCE  undoubtedly  plays  some  part  in  the 
production  of  malnutrition.  Small  size  and  inherited  feeble- 
ness of  constitution  may  be  transmitted  from  parents  to 
children;  but  there  is  a  dangerous  tendency  among  the 
laity,  and  even  among  physicians,  to  give  too  great  im- 
portance to  this  factor.  It  is  a  common  observation  that 
children  who  are  well  fed  and  carefully  brought  up  are 
regularly  larger  and  heavier  than  their  parents.  Heredity 
affects  height  much  more  than  it  does  weight.  It  should 
not  be  considered  as  an  important  cause  of  malnutrition 
unless  there  are  many  small  members  in  the  families  of 
both  parents.  Alcoholism  and  some  diseases  of  the  parents 
may  permanently  affect  the  child's  nutrition,  however. 


The  \ntritinn   r 


II.— PAST  ILLNESS. 

Prematurity  or  small  size  at  birth  may  give  a  child  a 
bad  start  from  which  he  never  entirely  recovers. 

Difficult  Feeding  in  infancy  or  disorders  of  digestion, 
either  acute  or  chronic,  especially  if  prolonged  or  frequently 
repeated,  prevent  a  normal  growth  and  gain. 

Acute  Illness,  such  as  severe  attacks  of  the  contagious 
diseases,  typhoid,  pneumonia,  surgical  infections  or  even 
frequent  colds  or  tonsilitis  may  cause  a  loss  of  weight 
which  is  recovered  very  slowly. 

While  past  causes  can  not  be  removed,  it  is  a  mistake 
to  overlook  them  or  to  minimize  their  importance. 

III.— PRESENT    DEFECTS  OR   DISEASE.— These 

can  be  detected  only  by  a  complete  medical  examination. 
A  nurse  or  teacher  can  observe  many  of  the  gross  defects 
such  as  decayed  teeth,  very  large  tonsils,  skin  lesions, 
bad  posture  or  flat  feet.  She  also  may  note  certain 
symptoms,  such  as  mouth  breathing,  cough,  shortness  of 
breath,  palpitation,  etc.,  but  it  is  evident  that  medical 
training  is  necessary  to  go  much  beyond  these.  There- 
fore, it  is  essential  that  every  nutrition  class  have  some 
medical  connection. 

A  medical  examination  should  include,  in  addition  to 
the  complete  physical  examination,  an  investigation  of  the 
blood,  urine  and  stools  when  possible.  A  skin  test  for 
tuberculosis  should  be  done  on  all  cases,  and  a  Wasser- 
man  test,  if  there  is  any  reason  to  suspect  syphilis. 

The  DEFECTS  most  frequently  found  are: 
Carious  Teeth — Chronic  absorption  from  decayed  or  in- 
fected teeth  certainly  causes  ill  health.     Quite  as  important 
is  the  imperfect  mastication  resulting  from  many  tender  or 
aching  teeth. 


The  Nutrition  Class 


8 


Diseased  Tonsils  are  also  a  cause  of  ill  health,  due  to  the 
the  chronic  absorption  of  pus  and  bacteria  from  their 
crypts.  Chronic  suppuration  in  the  ears  or  elsewhere  may 
be  the  cause  of  malnutrition. 

Obstructed  Nasal  Breathing,  especially  when  due  to 
adenoids,  results  in  chronic  oxygen  starvation  and  is  often 
associated  with  frequently  recurring  colds. 

Other  Defects  such  as  eye  strain  or  defective  hearing 
affect  a  child's  nervous  system  and  indirectly  his  general 
health.  Flat  feet  may  give  enough  discomfort  to  prevent 
proper  exercise  and  muscular  development.  Habitual  bad 
posture  may  be  quite  as  serious.  Mental  defect  is  often 
associated  with  poor  physical  condition;  therefore  mental 
tests  should  be  made  on  every  undernourished  child. 

PKESENT  DISEASE. — Tuberculosis  is  one  of  the  most  fre- 
quent causes  of  malnutrition.  This  does  not  mean  tuber- 
culosis of  the  lungs,  the  disease  usually  being  in  the  "glands" 

of  the  neck,  abdomen 


A  Complete  Medical  Exam- 
ination is  the  first  Step  in 
Detecting  Defect  and  Disease 


Ethical  Cvltvre  School  Children 
Supervised  by  Federation  of  Child  Study 


or  chest.  The  last  is  by 
far  the  most  frequent 
site.  The  tuberculin 
skin  tests  tell  us  whether 
a  child  has  been  infected 
and  is  of  value  at  any 
age.  Fever  combined 
with  malnutrition  usu- 
ally means  activity  of 
the  disease  process.  A 
careful  examination  for 
signs  of  bronchial  node 
involvement  (especially 
D'Espine's  sign)  and 
an  X-Ray  of  the  chest 
should  be  made  if  posi- 


9  The  Nutrition  Class 


live  skin  test  is  found.  The  intradermal  test  is  much 
more  accurate  than  the  usual  Pirquet. 

Other  Chronic  Diseases  must  be  ruled  out  before  a  child 
is  considered  as  merely  a  case  of  malnutrition.  It  is  obvious 
that  diabetes  or  chronic  kidney  disease  can  not  be  properly 
treated  in  a  nutrition  class.  Heart  disease  is  better  treated 
in  a  separate  class,  but  in  the  milder  degrees  the  treatment 
is  so  nearly  identical  that  the  cardiac  condition  need  not 
bar  a  child  from  a  nutrition  class  when  no  cardiac  class  is 
accessible.  Intestinal  parasites,  malaria,  blood  diseases, 
etc.,  must  be  considered  and  ruled  out.  Syphilis  also  affects 
nutrition  and  the  Wasserman  reaction  not  infrequently  sur- 
prises us  with  an  answer  to  a  difficult  case  in  which  no 
progress  is  made  by  the  usual  measures. 

IV.— BAD    HYGIENE    AND    IMPROPER    DIET. 

These  are  by  no  means  confined  to  the  poor  and  play  a 
part  in  almost  every  case.  It  is  necessary  for  the  nutrition 
worker  to  be  thoroughly  familiar  with  the  essentials  which 
make  up  good  "Health  Habits"  and  also  with  the  common 
errors,  so  that  an  intelligent  study  of  the  daily  life  may  be 
made. 

Insufficient  Food. — It  will  be  found  that  a  majority  of 
the  thin  children  take  too  little  food.  This  may  be  be- 
cause there  is  not  enough  food  available,  due  to  poverty  or 
bad  buying.  More  often  it  is  due  to  improper  training  by 
ignorant  or  careless  parents,  or  spoiling  by  over-indulgent 
ones.  Everyone  who  works  with  children  is  familiar  with 
the  child  who  eats  no  breakfast  or  lunch,  with  the  one  who 
simply  "picks"  at  his  food,  and  with  those  who  eat  no 
cereals  or  bread  or  milk  or  vegetables.  The  result  is  that 
an  insufficient  amount  of  food  is  taken  upon  which  proper 
growth  is  impossible. 


The  Nutrition  Class  10 

Improper  Food. — This  does  harm  in  two  ways,  first  by 
being  substituted  for  the  right  kind  of  food;  and  second, 
by  causing  disorders  of  digestion.  Tea  and  coffee  stand 
at  the  head  of  the  list  in  frequency  and  importance,  because 
they  are  used  in  place  of  milk,  and  because  they  are  too 
stimulating  for  the  sensitive  nervous  system  of  the  child. 

Candy,  soda  water,  cake,  pies  and  pastry  will  upset  the 
digestion  when  taken  regularly  or  in  large  amount.  Child- 
ren are  certainly  better  off  without  them.  If  given  at  all, 
candy  should  be  eaten  after  the  main  meal  of  the  day  and 
in  small  amount.  Ripe  fruits,  such  as  apples,  pears,  peaches 
and  bananas,  are  excellent  for  older  children  if  taken  with 
a  meal  in  moderation,  but  if  green  or  overripe,  or  if  eaten 
shortly  before  a  meal,  or  swallowed  in  large  chunks,  they 
may  cause  acute  indigestion  or  diarrhoea.  Pickles,  nuts 
and  sweet  preserves  tax  the  digestion  more  than  their  food 
value  justifies. 

Improper  cooking,  especially  frying,  spoils  much  good 
food.  Fried  potatoes,  fried  meat,  fried  eggs  form  a  large 
portion  of  the  diet  of  many  families. 

Too  much  meat  is  commonly  eaten.  Some  children 
take  too  much  bread  and  butter,  and  will  eat  nothing  else 
if  allowed  their  own  way.  Even  milk  may  be  drunk  to 
excess,  especially  from  the  second  to  the  fifth  year  A 
child  who  takes  three  or  four  pints  of  milk  a  day  will  sel- 
dom eat  enough  other  food  to  balance  his  diet. 

Bad  Eating  Habits. — Eating  too  fast  and  chewing  too 
little  are  almost  universal  habits  and  most  children  need 
constant  admonition  about  them.  Washing  food  down 
with  water  or  milk  is  nearly  as  frequent. 

Eating  too  slowly,  dawdling  at  the  table  is  seen  more 
often  among  children  in  better  circumstances,  and  may 
become  so  exaggerated  a  habit  as  to  cause  a  serious  con- 


11  The  Nutrition  Class 

dition  on  account  of  the  small  amount  of  food  taken.     This 
is  a  common  habit  of  the  only  child  of  an  anxious  mother. 

Constipation. — Constipation  or  irregular  bowels  are 
habits  of  the  majority  of  undernourished  children.  With- 
out a  regular  bowel  movement,  good  health  is  of  course 
impossible.  The  normal  time  is  after  breakfast  and  before 
school.  A  striking  improvement  in  the  health  will  fre- 
quently take  place  if  the  bowels  are  trained  to  move  in 
the  morning.  Constipation  results  in  poor  appetite,  indi- 
gestion, headache,  anaemia  and  general  ill  health. 

In  order  to  have  time  for  a  proper  morning  movement, 
a  child  must  get  up  early  enough  to  dress  and  eat  breakfast 
without  hurry,  and  then  have  20  to  30  minutes  free  for  the 
bowel  action  before  starting  for  school. 

Children  Amusing  Each  Other  While 
Awaiting  the  Doctor 


Ethical  Culture  School  Children 
Xuperriied  by  Federation  of  Child  Studg 

Insufficient  Sleep  and  Rest. — The  child  who  seldom  gets 
to  bed  before  eleven  or  twelve  o'clock  nearly  always  must 
be  wakened  in  the  morning  to  be  on  time  at  school.  He 
cannot  get  the  ten  or  eleven  hours  of  sleep  which  he  needs 
and,  next  to  food,  sleep  is  the  most  important  factor  in  a 
child's  life. 


The  Nutrition  Class  12 

The  daily  rest  period  is  omitted  too  early  by  most 
children.  It  should  be  continued,  after  the  noon  meal,  at 
least  up  to  the  school  age  and  really  is  needed  for  several 
years  later.  Rest  periods  ought  to  be  in  the  routine  of 
every  school  day,  as  they  are  in  open  air  and  other  special 
classes  in  which  thought  is  given  to  health. 

Insufficient  Fresh  Air. — Most  sleeping  rooms  have  not 
enough  ventilation  especially  in  the  winter.  Since  a  child 
spends  nearly  half  his  time  in  bed,  he  can  really  get  more 
fresh  air  by  night  than  by  day,  if  the  windows  are  wide 
open.  A  small  crack  or  opening  is  not  enough.  Both 
sashes  should  be  wide  open,  top  and  bottom.  If  a  child 
is  well  covered  and  screened  from  direct  draught,  the  more 
air  he  gets,  the  better  will  be  his  health. 

By  day  there  is  scant  time  out  of  doors  for  the 
school  child,  but  it  is  essential  that  he  should  go  out  after 
school  whenever  possible.  In  stormy  weather,  children 
may  play  in  a  room  with  open  windows  rather  than  sit  in 
closed  overheated  rooms. 

Insufficient  Exercise  or  Over  Exertion. — The  normal  play 
impulse  gives  most  children  sufficient  exercise.  The  under- 
nourished child  frequently  has  such  poor  muscular  develop- 
ment that  he  becomes  exhausted  by  a  normal  amount  of 
muscular  work.  This  results  either  in  chronic  over  fatigue 
or  else  in  the  gradual  giving  up  of  games.  In  other  child- 
ren excessive  exercise  is  a  common  fault  and  may  be  the  chief 
cause  of  the  failure  to  gain  weight. 

Uncleanliness. — The  tonic  effect  of  bathing  the  entire 
body  is  an  important  factor  in  promoting  good  health. 
Dirty  hands  and  faces  increase  the  danger  of  taking  bac- 
teria into  the  body.  Dirty  teeth  predispose  to  early 
decay. 


IS  The  Nutrition  Class 


v  V.— SOCIAL  FACTORS.— These  act  upon  the  child  in 
his  home.  They  are  partly  economic,  depending  not  only 
upon  the  social  status  of  the  family,  but  also  largely  upon 
the  personality  and  intelligence  of  the  parents,  and  upon 
the  atmosphere  of  the  home. 

Insufficient  Income  must  stand  at  the  head  of  the  list. 
It  is  the  main  cause  of  bad  housing  and  crowding  which 
mean  insufficient  air,  light  and  rest  for  the  child.  When 
there  is  not  enough  money  to  buy  food,  it  is  evident  that 
the  children  in  the  family  will  not  gain  adequately.  Pov- 
erty is  not  the  only  cause  of  malnutrition,  but  it  is  a  very 
definite  one,  and  in  many  cases  no  improvement  can  be 
expected  without  financial  relief  in  families  where  there  is 
simply  not  enough  to  go  around. 

Unintelligent  Buying  commonly  adds  to  the  difficulties 
of  the  insufficient  income.  The  extravagances  of  the 
poor  are  well  known  to  all  who  do  social  work.  Mothers 
must  be  convinced  that  money  spent  on  tea  and  coffee 
is  wasted  and  should  be  used  for  milk;  that  bulk  cereals, 
stale  bread,  dried  fruits,  and  vegetables  are  the  cheapest 
and  best  foods  and  should  be  bought  before  meat  is 
thought  about. 

The  Personality  of  the  Parents  and  the  atmosphere  of  the 
home  always  have  profound  influence  on  the  health  of 
the  child.  The  father's  habits  and  earning  capacity  directly 
affect  the  income.  His  temper  and  intelligence  must  also 
be  considered,  for  his  unreasonable  objections  to  any  changes 
in  the  family  routine  may  thwart  a  mother  who  would  like 
to  try  to  do  better  by  her  children.  The  mother  is,  of 
course,  the  center  of  the  family,  and  her  personality  in- 
fluences the  child's  whole  life.  The  irritation  engendered 
by  constant  quarreling  between  the  parents  or  children  has 
an  effect  on  the  nervous  system  which  may  be  reflected  on 
the  health  and  physique  of  the  child. 


The  Nutrition  Class 


ORGANIZATION  OF  THE  CLASS 

ATER  the  individual  causes  have  been  worked  out  for 
a  group  of  children  with  malnutrition,  it  is  evident 
that  some  form  of  class  treatment  is  the  most 
practicable  manner  of  handling  them.  They  all  need  the 
same  care  and  much  effort  may  be  saved  by  class  methods, 
but  the  individual  and  his  problem  must  never  be  forgotten 
in  the  routine  of  the  class. 

Classes  may  be  held  in  various  places.  Dispensaries 
have  long  neglected  the  child  with  malnutrition,  and  every 
well-organized  out-patient  department  should  have  a 
Nutrition  Class.  There  is  need  for  many  more  classes 
than  can  ever  be  conducted  in  dispensaries,  however,  and 
they  have  been  organized  in  settlements,  church  houses,  and 
most  important  of  all,  in  the  public  schools. 

The  school  is  the  place  where  most  of  the  classes  should 
be  conducted,  for  there  are  enough  children  in  every  large 
public  school  to  fill  several  nutrition  class  groups.  School 
classes  should  be  held  during  school  hours,  as  a  part  of  the 
regular  school  work.  When  this  is  impossible  the  Nutri- 
tion Class  may  have  to  meet  for  half  an  hour  after  school 
once  a  week,  but  more  than  this  should  not  be  taken  from  the 
child's  "free  time."  There  should  be  some  connection  with 
a  physician  who  can  examine  the  children  before  admission 
to  the  class,  and  at  intervals  thereafter  to  check  up  on  the 
original  diagnosis.  It  is  desirable  that  he  should  attend 
the  class  from  time  to  time,  though  not  absolutely  essential 
that  he  be  there  at  each  meeting.  The  school  physician 
is  the  natural  person  for  this  work.  When  he  can  not  do 
it,  the  children  may  be  sent  to  dispensaries  or  other  physi- 
cians for  examination  and  diagnosis,  but  this  plan  is  not 
satisfactory  and  is  not  recommended. 

The  school  class  has  many  advantages  over  all  others. 


16 


The  Nutrition  Class 


Regular  attendance  can  be  secured,  for  the  class  should  be 
made  a  required  part  of  the  school  regime.  The  atmos- 
phere of  education  is  a  help,  for  the  children  go  to  school 
to  learn,  and,  in  general,  believe  what  they  are  taught. 
Health  lessons  should  carry  more  weight  with  many  child- 
ren when  coming  from  the  teacher,  who  is  trained  in  methods 
of  instruction.  The  teaching  must  be  graded  appropriately 
for  the  children  of  different  ages. 

The  School  Lunch 
Offers  an  Opportu- 
nity for  Interesting 
Children  in  Good 
Foods 


Ethical  Culture  School  Children 
Supertiied  by  Federation  of  Child  Study 


A  properly  conducted  School  Lunch  offers  exceptional 
opportunities  for  education  about  foods,  cooking,  eating 
habits  and  so  forth.  Each  child  can  be  given  a  health 
lesson  with  every  meal  at  the  school  lunch. 

The  hospital  is  better  equipped  to  take  care  of  the 
difficult  cases,  or  those  who  have  failed  to  gain  in  one  of  the 
classes  held  in  school  or  settlement.  While  it  is  more 
difficult  to  obtain  regular  attendance  in  out-patient  depart- 
ments, this  can  be  overcome  by  a  systematic  follow-up 
system  and  such  classes  have  the  advantage  of  having 
physicians  and  an  organized  social  service  always  avail- 
able. Also  the  laboratory,  special  clinics  and  other  hos- 


The  Nutrition  Class  16 


pital  facilities  are  extremely  important  in  making  difficult 
diagnoses  and  carrying  out  treatment. 

Size  of  Class. — There  are  two  distinct  types  of  Nutrition 
Classes  according  to  size. 

1st.  Small  classes  restricted  in  number  to  15  or  20 
children.  In  a  class  of  this  size  more  thorough  study  and 
work  is  possible  and  the  results  are  accordingly  better.  It 
is  desirable  to  form  such  class  groups  for  the  especially  diffi- 
cult cases,  since  they  cannot  get  the  individual  attention 
which  they  need  in  a  class  of  larger  size. 

2nd.  Larger  classes  unlimited  in  number  in  which  60  to 
80  children  may  be  treated.  These  have  the  advantage  of 
reaching  and  educating  a  larger  number  of  families.  The 
results  are  apt  to  be  less  perfect,  since  each  child  gets  less 
attention  and  can  be  allowed  to  attend  less  regularly. 

Personnel. — No  matter  where  the  class  is  conducted  the 
success  or  failure  will  depend  upon  the  personality  and  in- 
sight of  the  class  leader  rather  than  upon  equipment  or 
situation.  Certain  general  principles  must  be  followed  but 
the  actual  methods  used  will  vary  with  the  class  of  children, 
their  age  and  the  limitations  of  the  staff  and  equipment. 
The  person  conducting  the  class  (the  "leader")  should  have 
some  idea  of  class  methods,  of  the  essentials  of  hygiene  and 
dietetics,  and  ought  to  know  something  of  the  important 
causes  of  malnutrition.  In  many  classes  as  conducted  at 
present  the  leader  is  a  physician,  in  others,  a  social  worker 
who  may  or  may  not  be  also  a  trained  nurse.  School 
classes  are  usually  conducted  by  the  teacher,  social  worker 
or  school  nurse.  After  some  months  of  experience  and 
some  special  training,  an  intelligent  volunteer  worker  may 
qualify  for  the  position  of  leadership. 

The  leader  must  be  the  executive  officer  of  the  class, 
and  see  that  a  systematic  routine  is  established  so  that  no 


17 


The  Nutrition  Clans 


important  part  of  the  work  will  be  overlooked  in  the  case 
of  any  child.  She  should  supervise  the  general  conduct  of 
the  class  meetings,  the  keeping  and  filing  of  the  records, 
the  systematic  weighing  and  measuring,  the  work  of  the 
social  visitor  and  the  class  assistants.  The  leader  can  in- 
terpret the  instructions  and  advice  of  the  physician  to  the 
parents  and  children  thus  saving  much  of  his  time,  and 
also  can  give  much  of  the  class  instruction.  Important 
qualifications  for  this  position  are  a  love  for  children  and  a 
knowledge  of  how  to  interest  and  stimulate  them. 


This  Teacher  Has  the  Interest  and  Attention  of  Her 
Children  as  She  Tells  Them  a  Health  Fairy  Tale 


Ethical  Culture  School  Children 
Superviied  by  Federation  of  Child  Study 


In  addition  to  the  class  leader,  an  ideal  class  organiza- 
tion should  have  several  different  types  of  workers: 

Physicians,  one  or  more,  depending  on  the  number  of 
children. 


The  Nutrition  Class  18 

A  social  worker  who  visits  the  home  and  keeps  the 
other  workers  informed  of  what  happens  outside  the 
class  room. 

A  dietitian  who  is  trained  in  teaching  about  foods,  cook- 
ing and  economic  buying.  She  may  teach  mothers 
in  classes  or  in  the  homes. 

Assistants,  either  paid  or  volunteer,  who  can  do  much 
of  the  routine  clerical  and  class  work.  With  a 
properly  devised  system  it  is  possible  to  use  assistants 
who  have  had  no  training  before  coming  to  work  in 
the  class.  An  intelligent  volunteer  will  often  become 
invaluable  in  a  very  few  weeks. 

In  most  cases  it  is  necessary  for  one  person  to  fill  two 
or  more  of  these  positions.  The  school  class  leader  may 
have  to  take  on  all  the  work  except  the  medical  examination, 
even  including  the  home  visiting,  and  with  excellent  results 
provided  the  class  is  not  too  large.  The  teaching  of  health 
habits  is  not  so  difficult  or  complicated  that  any  one  with 
a  love  of  children,  imagination  and  initiative  need  fear  to 
attempt  it. 

Equipment. — The  equipment  needed  is  comparatively 
simple.  The  essentials  are: 

A  quiet  room  large  enough  to  hold  the  class  and 
workers,  which  must  be  set  aside  for  this  work  alone 
during  class  hours. 

Desks  or  tables  for  the  workers,  accurate  scales  (not 
of  the  spring  type),  a  measuring  rod  or  tape,  a  chart 
showing  weight  and  height  standards,  chairs  or  benches  for 
the  class,  a  file  for  the  records.  An  examining  table  and 
screen  are  desirable. 

Printed  matter — some  of  which  is  indispensable.  Record 
forms  for  the  history  and  examination  upon  which  are 
printed  the  points  to  be  noted,  With  these  a  worker  with 


19  The  Nutrition  Class 

very  little  training  can  learn  to  take  an  excellent  history  in 
a  short  time. 

The  form  given  below  is  one  modified  slightly  from  that 
arranged  for  local  Red  Cross  nutrition  classes  by  a  com- 
mittee of  nutrition  workers. 

A  weight  chart  is  essential  for  every  case,  since  the 
graphic  weight  curve  carries  more  force  than  any  row  of 
figures.  Large  wall  charts  may  be  used  which  have  the 
advantage  of  being  easily  seen  by  the  entire  class.  In  a 
large  class  there  is  rarely  wall  space  for  all  the  charts  of 
this  form  and  a  smaller  weight  chart  which  fits  into  and 
files  with  the  history  may  be  used.  These  are  large 
enough  to  show  to  small  groups  of  children,  and  are  more 
convenient  to  handle  and  file.  The  weight  chart  illustrated 
in  the  appendix  has  the  advantage  of  being  dated  ready 
for  use.  It  may  be  used  for  the  weight  curves  for  two 
or  three  years  (since  it  covers  25  Ibs.). 

In  addition  to  the  essential  equipment,  there  is  much  use- 
ful material  available  if  funds  permit  its  purchase,  especially 
printed  matter  such  as  diet  lists,  hygiene  directions,  health 
booklets  and  literature  of  all  kinds  These  may  be  purchased 
of  various  organizations,  or  written  by  the  class  workers. 

A  home  record  slip  or  book  is  of  much  value,  either 
printed  or  made  up  by  the  child  from  a  copy  furnished. 

Wall  charts  help  to  drive  home  health  lessons.  They 
may  be  made  as  posters  by  the  children  or  workers,  and 
this  variety  is  often  better  than  those  published  in  more 
pretentious  form. 

A  food  exhibit,  composed  of  models  representing  various 
articles  of  food,  helps  in  teaching  children  exactly  what  they 
should  eat.  With  them  the  day's  ration  of  three  meals 
may  be  shown  at  each  meeting  of  the  class.  In  place  of 
food  models,  pictures  may  be  cut  from  magazines  and 
pasted  on  cardboard  to  show  the  same  points.  Each  child 


Nutrition  Class 


may  thus  make  his  own  "food  exhibit,"  and  the  lessons 
learned  in  making  it  increase  the  depth  of  the  impression. 


A   Food   Exhibit   Graphically 
Shows  the  Children  What  to  Eat 


The  objects  of  the  class  method  are: 

1.  To  save  the  time  and  effort  of  the  persons  conduct- 

ing the  class  by  group  handling  and  teaching  of 
children  and  parents. 

2.  To  arouse  the  group  spirit  and  to  stimulate  competi- 

tion among  the  children.  It  is  much  easier  to  get 
a  child  to  correct  his  habits  of  life  if  all  the  other 
children  in  a  class  are  doing  the  same  thing. 
Children  enjoy  competition  and  this  force  is  the 
most  valuable  ally  in  nutrition  work.  Emphasis 
should  be  placed  on  the  idea  that  proper  living 
and  good  health  really  are  a  game,  the  playing  of 
which  is  great  fun. 

The  principles  which  must  be  borne  constantly  in  mind 
in  conducting  all  Nutrition  Classes  are, 

1.  The  careful  study  and  diagnosis  of  the  individual  case. 

2.  Correction  of  all  remediable  defects. 

3.  Education  in  health  habits. 

4.  Correction  of  the  social  and  economic  factors  in  the 

home. 


The  Nutrition  Class 


ROUTINE  CLASS  OPERATION 
I.    DIAGNOSIS. 

AT  the  first  visit  the  History  is  taken  by  one  of  the 

/-\^  assistants,  then  revised  and  corrected  by  the  head 

of  the  class.      The  first  history  will   usually  need 

subsequent    additions    and  changes  as   the  study   of   the 

family   brings   up  new  data. 

,The  physical  examination  and  the  routine  tests  are 
made  and  recorded.  The  social  condition  of  the  home  is 
investigated  and  noted.  The  facts  are  gone  over  care- 
fully and  additional  questions  put  to  the  child  and  parent 
to  complete  the  history,  at  subsequent  visits. 

The  Diagnosis  must  be  made  from  the  completed  record 
and  the  probable  causes  of  malnutrition  recorded  in  the 
summary.  Alt  this  can  rarely  be  determined  at  the  first 
visit.  It  may  take  weeks  or  even  months  to  find  the 
answer  to  a  difficult  case. 

At  the  first  visit,  the  mother  should  always  be  present, 
and  both  parent  and  child  must  be  impressed  with  the 
seriousness  of  bad  health  and  poor  nutrition.  It  is  fairly 
easy  to  convince  a  mother  that  it  is  important  for  the  child 
to  grow  up  big  and  strong.  It  may  be  more  difficult  to 
make  the  child  feel  the  desirability  of  making  the  effort 
necessary  to  do  this.  Boys  may  be  appealed  to  on  the 
basis  of  athletics,  for  they  all  know  that  size  and  strength 
help  in  sports  and  games.  The  same  arguments  will  reach 
girls  to  some  extent,  but  the  better  looks  of  a  plump  and 
rosy  child  may  well  be  impressed  upon  them  also. 

It  is  necessary  to  convince  the  parent  that  the  Nutri- 
tion Class  can  help  to  make  a  healthy  child  out  of  an  un- 
dernourished one.  After  the  class  has  been  under  way  for 
a  time,  it  is  easy  to  do  this  by  showing  the  results  with 


TJie  Nutrition  Class 


AN  EXAMPLE  OF  A  COMPLETE  HISTORY 


n(  Orf*Miinrin>. 

.  NAME  dUtOvQ^vcL 
5" 


NUTRITION   RECORD 

Addre-      M   3  "2.  3d 


II,. i. T.  I. lien  by 


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PRESENT  HISTORY.  Ge«.  He.llh    9"-trU.  » 
Ckiel  ConpUi 


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-»£-~t   -67     -"-ft f.1-  -1^1.          How  lon»  nnderweirtl     S*^tl_, 

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>/ 
•factfi*  '*£~~        CORRECTIONS  AND  IMPRi 


>J 


nd.r.l         WHEN  DISCHARGED      Arent*  V.ri.lit.n  Item  SI.D J.r.l 

%        IT.  (iik-)  ">       ('•«  "'•'  ">•  ""  c« 

%       HT   C!±")  '••     ««•»»)          "•  •••  * 


SIZE  or  ORIGINAL  is  8}£  z  11 


The  Nutrition  Class 


THE  REVERSE  SIDE  OF  THE  HISTORY  SHEET 


PHYS.  KXAM. 


j~.Kgjg.wD 

DtFtCTS  (Gin  D.W.) 


PHTS.  (XAM.  ON  DIKHAKC* 


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OP  ORIGINAL  is  8H«  11 


The  Nutrition  Class  24 

other  children.  The  weight  charts  and  the  appearance  of 
strikingly  improved  children  offer  good  arguments.  Best 
of  all,  the  mothers  of  children  who  have  gained  are  always 
most  willing  to  testify  as  to  the  help  their  children  have 
received. 

At  the  first  visit  a  thorough  explanation  should  be  made 
to  the  mother  concerning  the  causes  of  the  child's  condi- 
tion, and  what  first  steps  must  be  taken  to  improve  it. 
The  diet  list  and  general  hygiene  instructions  should  be 
given  out  and  discussed  fully. 


II.     CORRECTION  OF  DEFECTS. 

DURING  the  preliminary  study,  steps  can  be 
taken  to  correct  remediable  defects.  This  is 
one  positive  means  of  making  over  the  hand- 
icapped child  who  will  not  gain  until  relieved  of 
certain  defects. 

The  dentist  is  our  first  ally  who  must  be  called  upon  to 
put  the  mouth  into  good  condition.  Decayed  teeth  must 
be  removed  or  filled,  even  if  first  teeth. 

When  it  comes  to  tonsils  or  adenoids,  the  child  must 
be  considered  as  well  as  the  throat.  An  operation 
always  causes  a  loss  of  weight,  and  it  is  often  best  to 
build  the  child  up  somewhat  by  other  means  before  sub- 
jecting him  to  it.  All  children  should  be  kept  in 
bed  for  five  to  eight  days  after  the  operation,  until 
the  throat  has  healed  and  the  appetite  and  strength 
have  returned. 

Defective  vision  should  be  corrected  by  proper  glasses. 
Flat  feet  may  be  helped  by  tilting  the  sole  of  the  shoe, 
exercises  or  proper  braces.  More  serious  defects  must  be 
referred  to  proper  specialists. 


The  Nutrition  Class 


III.     EDUCATION. 

THE  education  in  health  habits  and  diet  offers  the 
chief  field  for  class  instruction.     In  order  not  to  dis- 
courage   the    children    at   the   outset,    it   is  best  to 
gradually  work  each  child  into  the  routine  of  the  class  and 
not  let  him  feel  any  lessening  of  the  personal  interest  in 
him.     It  is  highly  desirable  that   parents  attend  classes 
with  their  children  as  often  as  possible. 

At  each  return  visit  the  child  is  weighed.  The  height 
need  only  be  taken  at  four-month  intervals.  The  weight 
is  noted  on  the  child's  record  and  on  the  weight  chart. 


Weighed  at  Each  Visit  and  Measured  Every  Four  Months 


Much  should  be  made  of  all  this.  The  child  (and  parent) 
must  know  how  much  he  weighs  and  how  much  he  has 
gained  as  well  as  what  he  ought  to  weigh.  They  should 
watch  the  plotting  of  the  weight  curve,  the  meaning  of 
which  must  be  explained  with  great  care. 

The  next  step  is  to  question  the  parent  and  the  child 
as  to  the  general  health  since  the  last  visit,  as  to  the  diet 
and  daily  regime,  and  as  to  how  the  instructions  have  been 
carried  out.  The  answers  must  be  recorded  on  the  rluirl. 
A  printed  form  for  the  return  visit  simplifies  this. 


The  Nutrition  Class  26 


AN  EXAMPLE  OF  THE  TYPE  OF  PRINTED  FORM  WHICH  is  USEFUL 
IN  TREATING  MALNUTRITION 

SCHEDULE  OF  DAY     -fa-     -M*^  C. 


OUT  OF  BED  at       7 

BATH  at     /4*vt«o  i*  t 

BREAKFAST  at      7  12. 

/    FRUIT 
f-  CEREAL 
J    MILK  OR  COCOA 

2  to  3  Tablespoon; 
*^to  5  Tablespoons 
1  to  2  Cup. 

Cooked  apples,  prunes,  pears,  peaches.     Orange  juice  or  pulp. 
1  Oatmeal,  Wheatena,  Malt  Breakfast  Food,  Pettjjohn's,  )  Cook  3  hours  in 
<  Ralston'  s  Cornmeal,  Farina,  Cream   of  Wheat,  Rice,  ^double  boiler  or 
'  Hominy.                                                                                  )  nreleas    cooker. 
Boil  1  teaspoon  cocoa  to  H  cup  water  and  add  Vj  cup  milk. 

^   BREAD  AND  BUTTER 
.  Er.f.- 

2  to  X  Slices 

Wheat,  whole  wheat,  graham  bread  (stale  or  toasted),  zwieback 

finfr  hailed   nnirhsd  nr  n  i  niiMi  il  iiilli  •ilk 

(Eat  ihaly,  elicit  uull,  Jo  not  vain  Joan  food  itllh  mala  or  milk.) 
BOWELS  anst  move  •&**.    Jr*&  °-^ 


/J 


I     MEAT 


OR  EGG 


Beef         Steak  (broiled),  Roast,  Stew,  Chopped  beef  (cooked  in  dry  pan 

or  broiled) 

Lamb        Chop  (broiled),  Roast,  Stew 
Chicken   Roast  or  Broiled  or  Fricasseed 
Fish  Cod,  Halibut.  Flounder,  Weakfuh  (boiled  or  baked) 


OR  SOUP  Thick  puree  of  peas,  beans,  lentils  or  any  thickened  ret;etabl«  soup 

v     STARCHY  VEGETABLE.  2^1  Tablespoon;    j  ^'"^"^i  b££'a  m"h"1'  crelm<:d)  "««P««0  «><'ik'1  «  "«* 

a     GREEN  VEGETABLE.       J.  to  3  Tablespoon/    j  gpin'ch   chard,  beet  tops  peas,  string  beans,  asparagus  tips,  carrott,  celerr, 

**  I  knob  celerr,  orMer  plant,  beets,  cauliflower. 

^     BREAD  AND  BUTTER.     1  n£?SIices 

!Rice  or.  bread  pudding,  Indian  meal  pudding,  junket,  custard,  cornstarch, 
gelatine,  ke  cream,  apple  sauce,  baked  or  stewed  applet,  stewed  dried 
apples  or  peaches,  stewed  pears,  slewed  prunes  or  prune  pudding. 
WATER 

NAP  OR  REST  from     /     to     2-   in  room  with  open  window 
AFTERNOON 


£  to  4  Tablespoon 

or  MILK  TOAST 

or  BAKED  POTATO 


V  MILK  1  to  2  Cup* 

3    BREAD  AND  BUTTER     2  yk  Slices 
H    DESSERT  3  V*k  Tablespoons        Cooked  fruit,  junket,  custard 

BED.!     q^_ 

Have  room  dark  and  cool,   windows  open  top  and  bottom,  bed  shielded  from  direct  draught    Child  should  be  in  sleeaiaf  bag  or 
well  pinned  in  so  that  bedding  can  not  be  kicked  off. 

NO  tea,  coffee,  soda  water,  cindy,  jelly,  sweet  preserves,  nuts,  raisins.     NO  fried  or  greasy  food. 

NOT  too  much  milk  (1  quart  is  enough.     Every  child  needs  at  least  1  pint  a  day).     NO  food  between  meals  unless  ordered. 

WATER.   1  glass  at  each  meal,  1  glass  in  mid  morning  and  mid  afternoon,  none  at  bed  time. 

GOOD  HABITS  AND  PROPER  FOOD  ARE  ABSOLUTELY  KECEMARY  FOR  GOOD  HRAITH  AND  PROPER  GROWTH. 

The  matter  printed  on  this  form  comprises  nearly  all  the 
facts  which  it  is  desirable  to  give  to  most  of  the  patients,  but 
it  is  necessary  to  write  in  the  specific  directions  for  the  individual 
case.  This  gives  elasticity  to  the  form  and  makes  the  parent 
feel  that  the  directions  are  for  her  child  in  particular.  This 
type  of  form  is  distinctly  for  the  parent  but  older  children  may 
also  be  interested  in  it. 


27 


The  Nutrition  Class 


THE  RETURN  VISIT  SHEET 


SOCIAL  suncx 


ACE 

WT.  ft  (AV.) 
HEIGHT 

TEMPCU 

PMTS.  EXAM,  kr 


.  ft) 


fi. 

3    - 


S    • 

M.F. 


/».•*• 
47  v 


y  J» 


U" 


-H     !.' 


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'.....  JL  .4f  , 


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bf  " 
3V  */  C 

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The  Nutrition  Class 


The  home  record  which  has  been  filled  out  during  the 
week  may  be  also  gone  over.  Much  of  the  teaching  in 
hygiene  can  be  done  at  this  time  by  the  social  worker  or 
volunteer  attendant. 

The  children  who  have  gained  and  who  have  done  well 
since  the  last  visit  are  now  brought  together  in  a  general 
class.  They  may  be  arranged  in  a  row  in  order  of  merit 
according  to  the  greatest  gain  for  the  week  and  rivalry 
should  be  stimulated  so  that  each  child  will  try  to  be  at 
the  head  of  the  class  the  following  week. 

Class  talks  to  parents  and  children  save  much  time  and 
have  often  a  better  psychological  effect  than  individual 
advice.  They  need  not  be  formal  nor  long  but  can  be  in- 
terspersed with  the  class  routine  whenever  a  text  presents 
itself  in  the  gain  or  loss  of  any  child.  Diet  and  hygiene 
offer  an  endless  number  of  subjects — proper  and  improper 
foods,  economic  buying,  methods  of  cooking,  food  values, 
the  various  kinds  of  food  and  their  functions,  habits  of 
eating,  sleep,  rest,  air,  exercise,  bathing,  teeth,  tonsils, 
etc. — in  fact  every  aspect  of  the  whole  problem  may  be 
talked  about  to  the  class  as  a  whole  or  in  groups  with  much 
saving  of  time. 

The  children  who  have  not  gained  should  be  con- 
sidered separately  and  their  charts  must  be  gone  over  to 
find  out  the  reason  for  the  failure.  It  is  necessary  to 
demonstrate  to  the  children  that  they  cannot  gain  unless 
all  the  laws  of  health  are  obeyed  all  the  days  of  the 
week.  Re-examination  of  the  child  must  be  made  at  in- 
tervals to  try  to  detect  signs  of  disease  which  may  have 
been  overlooked. 

A  good  many  children  will  not  gain  until  they  are  taken 
out  of  school.  Extra  rest  hours  or  a  week  or  two  of  rest 
cure  in  bed  may  be  necessary,  especially  when  the  appetite 
is  poor.  When  a  good  rate  of  gain  is  established,  school 


The  \utrition  Class 


may  IMJ  resumed  in  the  morning,  and  later  on,  for  the 
day. 

If,  after  a  considerable  period,  a  child  does  not  gain  at 
home,  he  may  be  sent  away  to  a  country  home  or  some 
similar  place.  Little  will  be  accomplished  by  a  short 
stay,  for  it  takes  two  weeks  for  most  children  to  become 
accustomed  to  the  new  routine.  One  or  two  months  are 
frequently  needed  to  produce  a  real  gain.  If  a  child  stays 
away  long  enough  to  gain  5  to  10  pounds,  he  will  get  an 
impetus  which  will  carry  him  on  after  the  return  home. 
But  unless  the  parents  and  child  have  been  educated  to 
the  necessity  of  proper  mode  of  life,  the  weight  gained  will 
soon  be  lost  after  he  comes  home,  because  the  real  cause  of 
the  trouble  has  not  been  reached. 

Great  patience  is  required  in  the  treatment  of  the  child- 
ren where  the  weight  deficit  is  great  and  the  chief  cause 
cannot  be  removed.  The  result  depends  upon  the  removal 
or  neutralizing  of  the  causative  factors  and  stimulating  the 
children's  interest  so  that  they  will  make  every  effort  to  gain. 

The  home  record  is  perhaps  the  best  means  of  finding 
out  what  the  child  is  really  doing  in  his  daily  life.  Each 
child  should  be  made  to  keep  one  for  a  week  at  a  time 
every  month  or  two.  The  record  should  show  the  time  of 
rising,  dressing,  bathing,  bowel  movement,  the  time  of  each 
meal  and  the  food  taken,  the  hours  in  school,  out  of  doors 
and  of  rest,  the  amount  and  kind  of  exercise,  the  bedtime 
and  hours  of  sleep. 

The  calories  taken  at  each  meal  may  be  kept  by  the 
older  and  more  intelligent  children.  This  is  undoubtedly 
a  most  valuable  means  of  stimulating  interest  in  the  food 
taken,  and  will  make  some  children  eat  properly  when  all 
else  has  failed.  It  is  a  simple  matter  to  teach  rough  caloric 
values,  for  average  portions  of  many  foods  fall  into  100 
calory  portions. 


The  Nutrition  Class 


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The  home  record  chart  shown  is  compiled  from  those  kept 
by  four  different  children  in  order  to  show  different  types  of 
record.  Each  day  is  copied  accurately  just  as  the  child  wrote  it. 

Monday  and  Tuesday  are  from  the  chart  of  a  very  intelligent 
girl  of  11  who  kept  accurate  account  of  her  entire  day,  as  well 
as  the  calories  she  took. 

Wednesday  and  Thursday  were  written  by  a  girl  of  12,  Fri- 
day and  Saturday  by  a  boy  of  11,  Sunday  by  a  girl  of  9. 

The  last  three  days  are  distinctly  poorer  records  than  the 
first  four. 

These  home  records  give  one  an  insight  into  what  the  child 
is  actually  doing  each  day,  in  a  way  which  is  not  equalled  by 
any  other  means. 


31  The  Nutrition  Class 

100  CALORY  PORTIONS 

Milk 5  ounces  1  glass — 150  cals. 

Egg 1  large  1  average — 75  cals. 

Meat 2  ounces  about  size  of  a  chop 

Fish 3       "  about  3x2x1  inches 

Pea  or  Bean  Soup . .  ..4  }/%  cup 

Bread 1  slice  about  4x4  x%  in  ches 

Cereals  (cooked) ....  /^-l  cup 

Macaroni .  1  cup 

Rice %  CUP 

Potato 1  medium 

Sugar 2  tablespoonfuls 

Butter,  Oil 1  tablespoonful 

Green  Vegetables 1  to  2  cups 

Prunes 4  average 

Apple,  Orange 1  average 

This  list  is  not  long  nor  complicated.  It  does  not  con- 
tain every  possible  article  of  food,  but  merely  those  which 
form  the  main  part  of  the  diet. 

Small  prizes  are  very  useful  means  of  stimulating  in- 
terest. Children  will  work  for  them  at  times  when  nothing 
else  will  make  them  gain.  A  prize  may  be  offered  to  an 
individual  child  if  he  will  make  his  weight  curve  reach  a 
certain  spot  at  a  certain  time.  Prizes  for  the  greatest  gain 
in  a  month  or  year  are  useful.  It  is  better  to  separate  the 
adolescent  from  the  younger  children  in  the  prize  offers, 
otherwise  the  older  children  will  get  all  the  prizes,  as  their 
normal  rate  of  gain  is  nearly  double  that  of  the  younger 
child.  Prizes  for  attendance,  for  resting  regularly,  for 
cleanliness,  for  clean  teeth  and  so  forth  will  all  obtain 
results.  Prizes  may  also  be  offered  for  the  best  home 
record  and  for  the  best  poster  which  illustrates  a  health  les- 


The  Nutrition  Class  32 

son.  This  makes  the  children  think  about  the  matter  in 
a  way  which  makes  a  lasting  impression. 

Stars  pasted  on  the  weight  chart  stimulate  younger 
children  especially.  Different  colors  may  be  used  to  indicate 
gains  in  weight,  clean  teeth,  daily  rests,  drinking  milk,  etc. 

Honor  rolls  showing  the  children  who  have  gainecLmost 
each  month  or  year  are  productive  of  effort  froni  some 
children.  They  should  be  legible,  preferably  printed  or 
written  large  and  brought  to  the  children's  notice  fre- 
quently as  a  great  honor. 

The  printed  matter  given  out  must  be  selected  with 
care,  especially  with  regard  to  the  age  and  intelligence  of 
the  child.  The  material  for  older  children  should  appeal 
to  their  reason  and  must  offer  them  really  desirable  rewards 
for  the  effort  they  must  make  to  change  their  mode  of  life. 
For  younger  children,  The  Child  Health  Alphabet,  health 
fairy  stories,  rhymes,  primers,  plays,  games,  etc.,  have 
proven  of  great  value  in  exciting  interest  in  subjects  other- 
wise hard  to  present  to  the  young.  It  is  a  tactical  mistake 
to  give  a  child  of  twelve  or  fourteen  a  nursery  rhyme.  Lit- 
erature written  over  the  heads  of  small  children  or  unintel- 
ligent parents  is  equally  useless. 

The  work  in  the  class  can  be  of  infinite  variety.  Every 
effort  must  be  made  to  keep  it  from  becoming  cut  and 
dried.  /  The  children  must  be  interested  first  of  all,  then 
amused  and  lectured,  scolded  and  praised,  bribed  and  brow- 
beaten by  turns.  No  one  method  will  reach  them  all,  but 
the  class  leader  who  wishes  to  succeed  must  be  prepared  to 
be  teacher,  friend  preacher  and  even  mountebank.  Above 
all,  he  must  study  child  nature  and  lack  self-consciousness 
in  his  dealings  with  children. 

Graduation. — Graduation  from  the  class  should  be  held 
up  as  a  very  great  honor.  Exercises  can  be  held  and  diplo- 


The  Nutrition  Class 


inas  awarded  with  some  ceremony.  The  "alumni"  of  the 
class  should  be  urged  to  attend.  A  short  talk  on  the 
causes  and  dangers  of  malnutrition;  on  how  to  keep  the 
health  they  have  gained;  an  exhibition  of  the  weight 
charts  of  the  graduates  and  an  explanation  to  all  the  child- 
ren and  parents  of  the  point  shown  on  the  charts  will  prove 
effective.  An  entertainment  may  well  be  added;  patriotic 
songs  may  be  sung  and  even  simple  refreshments  served. 

It  is  necessary  to  have  a  definite  standard  which  a 
child  must  reach  before  he  is  graduated.  He  must  first 
approximate  the  average  weight  for  his  height  and  age,  as 
determined  by  the  table  of  standards.  In  addition,  he 
should  have  all  remediable  defects  corrected.  His  teeth 
must  be  in  good  condition,  if  necessary  his  tonsils  must  be 
removed  and  his  defects  of  vision  corrected.  His  posture 
must  be  good  and  his  general  appearance  healthy.  Finally, 
his  daily  habits  and  diet  must  conform  to  the  teaching  in 
the  class  as  judged  by  his  own  reports  and  his  parent's 
testimony. 

The  purpose  of  the  class  should  not  merely  be  to  make  the 
child  gain  weight.  This  is  hard  enough  to  accomplish, 
but  unless  the  class  graduates  a  child  who  is  free  from  de- 
fects and  who  has  learned  good  health  habits,  it  has  failed 
in  its  complete  duty. 

IV.    WORK  IN  THE  HOME 

HOME  visits  by  a  nurse  or  social  worker  are  of  great 
importance.    Tact  is,  of  course,  the  prime  requisite  in 
order  to  secure  the  co-operation  of  the  whole  family. 
The  visitor  should  make  a  complete  study  of  the  home  and 
all  the  social  factors  in  the  case,  point  out  faults  and  help 
correct  them.      She  should  find  out  whether  instructions 
given  in  the  class  are  carried  out  and  note  all  points  which 


The  Nutrition  Class 


DIPLOMA 


This  is  to  certify  that 


has  graduated  from  the 

NUTRITION  CLASS 
i 

by   reaching   normal   weight   for   height    and 
age.     This  was  done  by  following  the 

RULES  OF  HEALTH 

EATING  THE  RIGHT  KIND  AND  RIGHT  AMOUNT  OF  FOOD 

EATING  SLOWLY,  CHEWING  WELL. 

SLEEPING  TEN  HOURS  WITH  OPEN  WINDOW 

RESTING  ONE  HOUR  A  DAY. 

KEEPING  CLOTHES  AND  BODY  CLEAN. 

BRUSHING  TEETH  AFTER  MEALS. 

HAVING  BOWELS  MOVE  BEFORE  SCHOOL. 

Date  Signed 


35  The  Nutrition  Class 

must  be  taken  up  at  future  meetings.  If  relief  is  needed, 
she  should  refer  the  family  to  the  proper  agencies. 

A  great  deal  of  educational  work  can  be  done  in  the 
home,  particularly  in  regard  to  the  preparation  of  proper 
food,  cooking,  regularity  of  meals  and  cleanliness. 

The  correction  of  defects  depends  largely  on  the  social 
worker  for  she  must  see  that  the  child  is  taken  to  the  spe- 
cial clinics  or  physician. 

In  brief,  it  rests  with  the  social  worker  to  convert  the 
advice  given  in  the  class  into  action. 

RESULTS 

THE  results  which  may  be  expected  will  depend 
upon  many  factors.  The  size  of  the  class,  equip- 
ment, the  number  of  workers,  and  most  of  all,  the 
personality  of  the  leader. 

In  a  small  class  nearly  all  of  the  children  can  be  made 
to  gain  at  a  good  rate,  providing  there  is  not  serious  disease. 
In  a  large  class,  fully  two-thirds  of  the  children  may  be 
expected  to  do  well.  The  remaining  third  should  be  trans- 
ferred to  smaller  classes  for  more  careful  study. 

A  result  may  be  considered  good  if  a  child  gains  at 
better  than  the  average  rate  for  his  age.  One  must  not 
expect  to  graduate  all  children  within  a  few  weeks  or  months, 
since  some  of  them  will  be  20  or  30  pounds  underweight,  and 
it  may  take  several  years  for  them  to  graduate.  A  study 
of  the  histories  and  weight  charts  of  many  children  makes 
it  evident  that  without  attention  the  weight  will  often  remain 
stationary  for  a  year  or  two  at  a  time.  In  the  more  severe 
cases  it  is  a  triumph  to  obtain  even  an  average  rate  of  gain. 

When  the  weight  deficit  is  only  five  pounds  or  less,  and 
where  the  cause  is  easily  discovered  and  removed,  a  child 
may  be  graduated  within  a  few  months.  ' 


The  Nutrition  Class 


36 


NUTRITION  CLASSES  are  really  HEALTH  CLASSES. 


i\ 


^T""\HE  real  place  for  the  nutrition  work  is  in  the  home  and 

school.    Parents  must  be  taught  that  malnutrition  may 

be  prevented  by  proper  feeding  and  training  of  children 

during  the  pre-school  age  as  well  as  during  school  life.    They 

must  learn  to  watch  weight  and  growth,  to  record  it  system- 

atically and  most  of  all,  to  realize  that  a  failure  to  gain  regu- 

larly is  a  warning  signal  that  the  child  is  not  in  good  health. 

Every  school  teacher  must  learn  to  teach  health  habits 

in  a  way  to  make  them  living,  vital  matters  rather  than  dry 

axioms  of  "physiology"  or 
The  ABC  of  Health  Made  Vital       "hygiene"    as    they    have 

been  in  the  past.  When 
every  school  has  proper 
health  teaching,  malnu- 
trition will  be  less  pre- 
valent. Physical  educa- 
tion as  too  often  practiced 
is  not  health  education 
and  does  not  meet  the 
children's  greatest  need. 
Nutrition  Classes  have 
already  demonstrated  what 
can  be  done  with  under- 
nourished children.  The 
special  Nutrition  Class 
will  probably  always  have 
a  place  in  the  school  for  the 
milder  cases,  and  in  the  hospital  for  the  more  severe  ones. 
Malnutrition  may  not  be  expected  to  disappear  in  a  short 
time,  but  will  undoubtedly  diminish  if  we  persevere  in  the 
education  of  children  and  parents  in  the  proper  habits  of 
living  which  will  do  much  to  prevent  its  development. 


Ethical  Culture  School  Children 
Supervised  by  Federation  of  Child  Study 


APPENDIX 


78349 


ILLUSTRATIVE  CASES 

The  Weight  Chart 

THE  form  of  the  weight  chart  is  of  no  small  impor- 
tance. Those  illustrated  below  have  been  in  use  at 
Bellevue  Hospital  for  over  five  years  and  have 
proven  entirely  satisfactory. 

Each  small  square  represents  one  week  in  the  horizontal 
direction  and  half  a  pound  in  the  vertical — the  chart  cov- 
ering 1  year  and  25  Ibs.  The  dates  are  printed  at  the  top 
so  that  they  need  not  be  written  in,  which  saves  much  time. 
The  horizontal  lines  are  numbered  in  the  margins  from  1 
to  0  so  that  it  is  merely  necessary  to  fill  in  the  tens  place 
with  the  numbers  showing  the  range  of  weight  which  the 
chart  covers  (i.e.,  if  a  child  weighs  75  Ibs.  the  bottom  line 
would  be  marked  70  and  the  next  heavy  zero  line  80.  It 
is  not  necessary  to  mark  in  all  the  figures  opposite  the 
other  lines). 

Then  find  the  date  at  the  top  on  which  the  child  was 
weighed  and  follow  this  vertical  line  downwards  until  you 
cross  the  horizontal  line  representing  the  exact  weight  and 
make  a  dot  at  this  juncture.  It  is  very  easy  to  interpolate 
between  the  lines  if  the  weight  is  taken  on  a  day  between 
those  indicated,  e.g.,  a  child  comes  in  weighing  72  Ibs.  on 
February  12,  1917  (see  Chart  A.  H.).  He  is  weighed  next 
on  February  22nd,  and  weighs  73^.  The  date  February 
22nd  does  not  come  on  a  vertical  line  but  is  2/7  of  the 
distance  between  the  lines  for  February  19th  and  February 
26th.  The  fraction  of  a  pound  can  be  estimated  in  the 
same  way  between  the  horizontal  lines. 

If  the  first  weight  is  a  multiple  of  10  it  is  well  to  begin 
ten  pounds  from  the  bottom  to  allow  for  possible  losses. 

It  is  best  to  write  in  the  year  in  the  left-hand  margin, 
to  show  the  year  covered  by  each  curve.  Since  the  chart 


39  The  Nutrition  Class 

covers  25  Ibs.  vertically,  it  may  be  used  for  more  than  one 
year  if  desired.  If  this  is  done,  the  average  line  cannot 
be  shown. 

At  subsequent  visits  the  weight  is  plotted  in  the  same 
way,  and  the  dots  connected  by  a  line,  thus  giving  a  con- 
tinuous weight  curve. 

If  it  is  desired  to  plot  the  Average  Weight  Line,  first 
determine  from  a  table  the  average  weight  for  the  child's 
age  and  height,  and  mark  this  point  on  the  chart. 

Since  most  children  gain  about  five  pounds  a  year 
before  twelve  years  and  ten  pounds  a  year  after  twelve 
years,  it  is  fair  to  assume  that  the  average  line  should 
have  a  slant  upward  from  left  to  right  corresponding  to 
these  figures.  Therefore,  with  a  ruler,  dot  in  a  line  which 
passes  through  the  "average  point"  and  which  has  a  slant 
of  five  or  ten  pounds  between  the  left  and  right  margins. 

Another  method  of  plotting  the  average  line  is  as  fol- 
lows: First  determine  from  the  table  and  plot  the  average 
weight  point  for  the  child's  height  and  age.  Note  the 
amount  which  a  child  should  gain  each  month  as  shown 
on  the  table.  Then  count  the  number  of  months  be- 
tween the  "average  point"  and  the  right-hand  margin, 
and  multiply  by  the  number  of  ounces  of  average  gain. 
This  will  show  how  many  ounces  the  "average  line"  should 
cover  between  the  "average  point"  and  the  right  margin— 
or,  in  other  words,  gives  the  slant  of  the  "average  line." 

The  advantage  of  the  dated  chart  is  its  great  saving  of 
time  and  trouble.  It  may  seem  a  disadvantage  to  some 
that  the  weight  curve  does  not  always  start  at  the  left- 
hand  margin,  but  it  is  really  not  necessary  that  it  should 
start  there.  What  we  want  to  show  is  the  progress  of  the 
child's  weight,  and  it  matters  little  where  the  weight  curve 
begins.  If  it  is  started  late  in  the  year  it  can  easily  be 
continued  after  January  1st  starting  at  the  left-hand  side. 


The  Nutrition  Class  40 

This  chart  when  used  for  several  years  shows  seasonal 
variations  in  the  child's  weight.  It  is  desirable  to  write 
on  the  chart  the  cause  of  marked  losses  or  gains.  The 
facts  to  be  noted  should  always  be  written  below  the 
weight  line,  not  above  it.  If  written  above,  they  may  use 
space  needed  for  the  next  year's  weight  curve. 


M.  C.     Admitted  Nov.  11,  1916.     Age  9  years,  l^j  months. 
Irish  descent.     Eldest  of  five  children. 

Father,  a  bartender  (misrepresented  income  to  social  worker). 
Mother  has  never  cooperated  and  very  rarely  attends  class. 
Home  conditions  very  bad,  4  rooms,  2  dark. 

Cooking  fair;  food  fairly  abundant. 
Past  History  —  Early  history  uneventful.    Measles  at  \y%  years. 

Pneumonia  at  2  years.     Colds,  very  frequent. 
Habits  —  Breakfast:   Cereal,  tea,  roll. 

Dinner:  Meat,  potato,  tea. 

Supper:   Bread,  tea.     Nothing  between  meals. 

Appetite  very  poor. 

Bowels  irregular. 

Sleeps  well.     Retires  at  9,  up  at  7:30.     Window  open. 

Never  rests. 

Wets  bed  every  night. 

Out  of  doors  after  school,  active. 
Present  History  —  Brought  on  account  of  poor  appetite,  frequent 

colds,  bed  wetting. 
Physical  Examination  —  Bright,  alert  child. 

Color  pale.       Posture  fair.  Wt.  45  Ibs. 

Nutrition  very  poor,  muscles  poor,  very   Ht.  49  ins. 
little  fat,  bones  slender.  Av.  Wt.  56  Ibs. 

Nose  obstructed  by  large  adenoids,   breathes   through 
mouth. 

Tonsils  very  large  and  irregular;   need  removal. 

Teeth  —  two  carious. 

Heart,  lungs  abdomen  —  normal. 

D'Espine's  sign  to  III  dorsal  vertebra. 

Von  Pirquet  test  strongly  positive. 


41 


The  \utritian  Class 


Summary — Home  conditions  unfavorable,  mother  unwilling  to  l>e 
bothered,  careless. 

Diet  insufficient,  (tea),  poor  appetite. 
Nasal  obstruction,  hypertrophied  tonsils,  frequent  colds. 
Tuberculous  infection  (probably  latent). 


The  Nutrition  Class 


Procedure — Instruction  in  hygiene  and  diet  in  class  and  at  home 
by  social  worker.     Little  response  from  parent. 

Enuresis  cured  at  once  by  correct  regime. 

The  weight  curve  showed  the  usual  small  initial  gain, 
then  a  long  stationary  period  until  Sept.,  1917,  when 
the  parents  at  last  consented  to  a  tonsillectomy.  Fol- 
lowing this,  there  was  a  gain  of  4  Ibs.  The  loss  in 
November  was  attributed  to  coffee  being  substituted 
for  milk. 

In  January,  1917,  a  prize  was  offered  if  the  child  would 
gain  5  pounds  in  three  months,  that  is,  if  she  could 
make  her  weight  curve  reach  the  point  marked  "A." 
An  immediate  gain  began,  but  not  quite  to  the  re- 
quired point.  She  was  then  sent  to  a  country  home 
for  five  weeks  and  gained  2  pounds. 

The  dotted  line  represents  the  time  when  no  classes  were 
held  during  the  war.  She  had  influenza  in  October, 
1918. 

On  her  first  visit  to  the  class,  November  12,  1918,  she 
was  again  offered  a  prize  if  she  could  gain  5  pounds, 
reaching  point  "B"  by  March  1st.  Her  weight  curve 
responded  at  once,  and  she  would  have  reached  "B" 
but  for  a  cold.  She  was  given  the  prize  the  next 
week. 

For  the  next  four  months  there  was  practically  no  gain — 
since  the  incentive  was  lost.  She  gained  fairly 
through  the  autumn  and  very  well  at  Holiday  Farm 
in  December.  The  winter  and  spring  of  1920  illus- 
trate well  the  effect  of  various  factors  on  the  weight 
curve.  In  every  case  where  there  was  a  loss  it  was 
possible  to  find  some  definite  cause. 

This  child  was  11  pounds  or  20%  underweight  on  admis- 
sion at  9  years.  She  was  still  16  pounds  or  17%  un- 
derweight at  13}/£  years.  She  is  not  a  brilliant  suc- 
cess therefore,  but  her  case  is  worth  recording  because 
it  shows  the  effect  on  the  weight  curve  of  so  many 
different  factors. 

Although  she  has  never  graduated,  yet  the  class  has  held 
the  child's  interest  and  she  has  kept  on  trying.  She 


43  The  Nutrition  Class 

has  no  help  whatever  at  home.  The  bad  nasal  ob- 
struction and  habit  of  mouth  breathing  which  persisted 
after  the  operation  and  the  tuberculous  infection  (even 
if  latent),  have  been  two  serious  handicaps.  It  seems 
fair  to  assume  that  under  the  circumstances  a  gain 
of  32J/2  pounds  in  the  4j/£  years  is  more  than  she 
would  have  gained  without  the  Nutrition  Class. 
S.  W.  10  years  11  months.  Jewish.  Admitted  to  Class 

Aug.  11,  1920. 

Father  in  good  health.     Mother  asthmatic. 
Eight  children,  all  living  and  well,  eldest  25,  youngest  6. 
Home — 5  rooms,  all  light,  fairly  clean. 

Rent  $25  a  month,  son  pays  half. 

Income — father  $16.00;   twro  children  work. 

Mother   fairly   intelligent    and    very    responsive,    needs 

instruction. 
Early  History — Normal.      Measles  at  9,  colds  and  sore  throats 

frequent.     Operation  on  tonsils  2  years  ago. 
Habits — Breakfast:  coffee,  eggs. 
Dinner:   Potato,  milk. 
Supper:   Cereal,  milk  or  tea,  bread. 
Appetite  good.      Bowels  move  after  breakfast. 
Bed  at  10,  up  at  8.     Window  open. 
School  9-12,  1-3.     Out  rest  of  day.     Very  active  child. 
Present  History — Brought  for  undernutrition. 
Chief  Complaints — Occasional   dizziness,   frequent  colds,   mouth 

breathing. 
Physical  Examination — (Abstracted) . 

Aspect  normal,  bright  child,  school — grade  5A. 

Color,  fair.  Weight,  58.6  clothed. 

Nutrition  poor,  muscles  fair.  Height,  52. 

Cervical  lymph  nodes  enlarged.      Av.  Wt.  for  Ht.,  66. 

Tonsils:  right  out,  left  large,  cryptic.     12%  underweight. 

Breathes  through  mouth. 

Teeth — severa  carious. 

Heart,  lungs,  abdomen — normal. 

Von  Pirquet — negative. 

Intradermal  tuberculin  1/100  mgm. — negative. 


The  Nutrition  Class 


44 


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Summary  of  Probable  Causes — Mother  ignorant  concerning  proper 

care  and  feeding. 
Frequent  colds  and  sore  throats. 
Diet  unbalanced. 
Sleep  insufficient;   no  rests. 
Overactivity. 
Mouth  breathing,  diseased  tonsil,  carious  teeth. 

Procedure — Preliminary   instruction   in   diet   and  health   habits, 
which  was  well  received  by  both  mother  and  child. 
Operation  on  adenoids  and  left  tonsil.     After  one  week's 
rest  sent  to  country  for  three  weeks.      There  was  a 
net  gain  of  three-quarters  of  a  pound  in  eight  weeks. 
(Child  probably  lost  weight  after  operation  and  re- 
gained it  in  the  country.) 
Teeth  put  in  order  and  kept  so  by  dentist. 


The  Nutrition  Class 


The  child  followed  directions  carefully  except  that  she 
objected  to  green  vegetables.  She  took  one  quart  of 
milk  daily,  rested  one  hour  a  day  and  was  in  bed  by 
8  P.M.  each  night. 

She  reached  the  normal  weight  line  Nov.  24,  was  grad- 
uated and  given  a  diploma. 

She  returned  two  weeks  later  with  a  gain  of  nearly  a 
pound  more. 

April  26,  1921.  Returned  for  observation.  Looked  like 
a  different  child. 

Weight  81^  Ibs.  Height  53^  in.;  13  Ibs.  or  19% 
overweight. 

This  child  is  an  example  of  what  can  be  done  in  a  favorable 
case.  The  home  conditions  were  good.  The  mother  was  ig- 
norant but  anxious  to  learn  and  very  eager  to  cooperate.  There 
was  no  serious  organic  disease  and  the  defects  were  correctable. 
The  child  followed  directions  and  attended  regularly.  She  was 
12%  underweight,  graduated  in  2^/2  months,  and  in  4  months 
more  became  19%  overweight. 


CHILD  HEAL' 
6RGANIZATI 

HI    AMEKI 
EKN  TERMINAL  WILDING 
SEVENTH  AVENUE 

,NEW  YOM  i.l  n       1 


Ml    balh 
once  a  week. 
Drinking   ai   much    milk 
at  poMiblc.  but  DO  cofee 

Of  1C*. 


or  Iruil  every  day. 

Drinking     at     leafl     four 

(Uue>  oi  walef  a  day 

A  bowel 

day. 

Pitying  pact  of  rvay  Amy 

out  oi  doon. 

long  hom  wihi 

op»«. 


The  Nutrition  Class 


A-H- 


MnofBKiH  AUG-I6-I9O4      >ct  IQi, 

JUI,-       I       »UO-      I       5KP        I       ocr       I       NOV       I       V 


?%  J  . f:r  7! 


in         MAY 


mr 


j    "    "i 


A.  H. — THIS  CHART  SHOWS  THE  IMPORTANCE  OF  DRINKING  MILK. 

The  dotted  portions  of  the  curve  represent  the  time  during 
which  this  child  took  no  milk,  the  solid  portions  the  time  during 
which  she  drank  one  quart  of  milk  a  day.  Note  that  nearly  all 
her  gains  were  made  while  she  was  taking  milk. 

The  other  factors  remained  about  the  same  during  these  two 
years. 

The  home  conditions  were  fair,  but  the  income  and  food 
insufficient. 

Her  habits  of  living  were  good,  but  the  diet  was  poor. 

She  was  a  tall,  slender  girl  with  flat  chest,  poor  muscles  and 
fat,  and  retarded  mentally.  She  had  three  carious  teeth,  buried, 
irregular  tonsils,  and  a  4  plus  Von  Pirquet  reaction.  She  was 
16  pounds  or  18%  underweight.  At  the  end  of  two  years  she 
was  13%  underweight.  Although  the  home  conditions,  mental 
retardation  and  other  causes  could  not  be  removed,  nevertheless 
this  girl  gained  at  somewhat  better  than  the  average  rate. 


CHILD  HEALTH  ORGANIZATION 

OF     AMERICA 

The  CHILD  HEALTH  ORGANIZATION  has  undertaken  a  nation-wide  campaign  to 
raise  the  health  standard  of  the  school  child. 

The  Organization  will  be  glad  to  know  your  community  problems,  make  sug- 
gestions for  local  work,  furnish  a  speaker  if  expenses  are  paid,  and  supply 
literature  at  cost. 

HEALTH  CLOWNS,  and  other  DRAMATIC  CHARACTERS,  trained  by  this  Organiza- 
tion are  available  for  engagements  throughout  this  Country  and  Canada. 
Single  performances,  $25;  two  performances  in  one  day,  $35,  plus  living 
and  traveling  expenses. 

Literature 


Weight  Cards — Tags — Posters. 
Health  in  Play— My  Health  Book. 
Standards  of  Xulrition  and  Groirth. 
The  Demonstration  and  Its  Application. 
The  Nutrition  Cla**. 
Alphabet  Cards,  A  to  Z. 

(Reverse  side  blank,  suitable  for  local 

notices  or  clinic  instructions.) 
Cho-Cho's  Health  Game. 


Health  Plays  for  School  Children. 
Rosy  Cheeks  and  Strong  Heart. 
Rhymes  of  Cho-Cho's  Grandma. 
Cho-Cho  and  the  Health  Fairy. 
Child  Health  Alphabet. 
Four   Plays   Dramatizing   "Cho-Cho 

and  Health  Fairy"  stories. 
Happy's  Calendar. 
.\filk,  The  Master  Carpenter. 


Price  List  furnished  upon  application 

Order    from     the     CHILD      HEALTH     ORGANIZATION     OF    AMERICA 

PENN  TERMINAL  BUILDING  370  SEVENTH  AVENUE  NEW  YORK  CITT 


THE  U.  S.  BUREAU  OF  EDUCATION 
has  arranged  for  the  sale  of  the  following  Reprints: 


Summer  Health  and  Play  School. 
Teaching  Health. 
Further  Steps  in  Teaching  Health. 
The  Lunch  Hour  at  School. 
Health  Training  for  Teachers. 
Your  Opportunity  in  the  Schools. 


Class-Room  Wight  Record. 
Right  Height  and  Weight  for  Boys. 
Right  Height  and  Weight  for  Girls. 
Wanted:     Teachers  to  Enlist  for  Health 

Service. 

Diet  for  the  School  Child. 

Child  Health   Program  for  Parent-Teacher  Suggestions  for  a  Program  for  Health 

Associations  and  Women's  Clubs.  Teaching  in  the  Elementary  Schools. 

Orders  for  these  should  be  sent  to:   The  Superintendent  of  Documents, 

Government  Printing  Office,  Washington,  D.  C. 

(Remittance  must  accompany  all  orders.) 

CHILD  HEALTH  ORGANIZATION  OF  AMERICA 

BOARD  OF  TRUSTEES 
DR.  L.  EMMETT  HOLT,  Presided 
DR.  THOMAS  D.  WOOD,   Vice-Prcxideru 
DR.  FREDERICK  PETERSON.  Srxretaru 
JAMES  G.  BERRIE.V,   Treaturer 
MRS.  JOHN  COLLIER 
CLINTON  H.  CRANE 
DR.  SAMUEL  McC.  HAMILL 
DR.  ROYAL  S. 


DR.  VICTOR  G.  HEISER 


STAFF 
SMI.T  LUCAS  JEAN.  Dirrctor 

Associate  Director! 

MARIE  L.  ROSE  ANNE  L.  WHITNEY 

ANNE  RAYMOND.  Field  Representative 

Assistant* 

MARGARET  C.  CAREY  GRACE  T.  HALLOCK 

ALICE  F.  LOOMIS 
Adritory  Directors 

3.    M.\CE    .\\DRB88  LUCY    OpPEN 


OWEN  R.  LOVEJOT 
MRS.  FREDERICK  PETERSON 
DR.  BERNARD  SACHS 
MRS.  FRANK  A.  VANDERLIP 
DR.  PHILIP  VAN  INOEN 
MH.  ALLAN  WARDWELL 
Miss  FLORENCE  WARDWELL 
DR.  HERBERT  n.  WILCOX 
DR.  C.-E.  A.  WINSLOW 


University  of  California 

SOUTHERN  REGIONAL  LIBRARY  FACILITY 

405  Hilgard  Avenue,  Los  Angeles,  CA  90024-1388 

Return  this  material  to  the  library 

from  which  it  was  borrowed. 


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Utoiversit 

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